Question: What are the key factors for seventh-character coding?
Answer: Seventh-character extensions usually are required for injuries, poisonings, and external causes. There are other codes that require seventh characters, but these are the most common.
Often, seventh characters designate episodes of care, such as an initial service (A), a subsequent service (D), or a sequelae (late-effect) (S). Seventh characters must be placed in seventh placeholders. If the base codes are only 3, 4, or 5 digits long, an ‘X’ is used as a placeholder, so the seventh character can be in the seventh space.
Sometimes, a D is used to code a second or later visit, treating it as a subsequent service. Clarification is needed.
Remember, seventh-character extensions are determined by patients’ treatment phases, not by the number of visits. It is also important during different phases to ensure base codes remain the same. For example, a patient with third-degree burns to the right forearm, would have an initial treatment reported as T22.311A. If significant scarring occurs and now the visit relates to loss of range of motion because of formed scar tissue, the diagnosis for that visit would be as follows: L91.0, T22.311S
The S or sequela should never be a primary or standalone diagnosis. The complication should be captured initially.
Fractures are complicated, as they also have seventh-character extensions, but have the following additional seventh-character options that provide more information about the fracture itself.
- A (Initial encounter for closed fracture)
- B (Initial encounter for open fracture)
- D (Subsequent encounter for fracture with routine healing)
- G (Subsequent encounter for fracture with delayed healing)
- K (Subsequent encounter for fracture with nonunion)
- P (Subsequent encounter for fracture with malunion)
- S (Sequela)
The use of A, D, and S does not change, as they are reported to capture episodes of care. However, if there is nonunion, malunion, or delayed healing, there are other seventh characters to consider. These should be supported by provider documentation and are crucial to capturing true patient status and determining future care.
When to Use Seventh Character Extensions
Open fractures can be more complex because the Gustilo Fracture Classification, which not all coders may be familiar with, may be needed to accurately assign seventh characters. In addition, providers may not be aware that this classificaiton is required to support patient acuity specificity. Gustilo classifications break open fractures into Type I, Type II, and Type III (Type III has further subdivisions), and identify the characteristics of the degree of the bone injury or involvement, the extent of the soft tissue damage, and the mechanism of the injury. The following additional choices are captured on some fracture types and should be shared with providers:
- B (Initial encounter for open fracture, Type I or II)
- C (Initial encounter for open fracture, Type IIIA, IIIB, or IIIC)
- E (Subsequent encounter for open fracture, Type I or II, with routine healing)
- F (Subsequent encounter for open fracture, Type IIIA, IIIB, or IIIC, with routine healing)
- H (Subsequent encounter for open fracture, Type I or II, with delayed healing)
- J (Subsequent encounter for open fracture, Type IIIA, IIIB, or IIIC, with delayed healing)
- M (Subsequent encounter for open fracture, Type I or II, with nonunion)
- N (Subsequent encounter for open fracture, type IIIA, IIIB, or IIIC, with nonunion)
When assigning seventh characters, there is no option for unspecified. You must always code to the highest degree of specificity to capture the condition. When unknown, coders should default to a closed fracture if the documentation does not indicate an open or closed fracture.
Jennifer Swindle is vice president, quality and service excellence, Salud Revenue Partners, and a member of HFMA’s Indiana Pressler Memorial Chapter.
